Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

Saliva is produced from three paired major salivary glands: the parotid glands, submandibular glands, and sublingual glands. In the resting state, 70% of salivary flow is from the submandibular gland. The parotid gland secretes primarily in response to food ingestion. Salivary secretion is under the control of the autonomic nervous system. The major glands secrete in response to olfactory, tactile, and gustatory stimulation. The resting secretory rate of 15 cc/hour increases 10 fold upon stimulation.

Salivary gland innervation is complex. Parasympathetic fibers to the submandibular gland originate in the superior salivatory nucleus and travel with the nervus intermedius to the facial nerve. These fibers exit with the chorda tympani and are conducted with the lingual nerve to the submandibular ganglion. Parasympathetic fibers to the parotid gland originate in the inferior salivatory nucleus in the medulla. These fibers leave on the glossopharyngeal nerve and continue on Jacobson's nerve. The lesser superficial petrosal nerve joins the otic ganglion where post ganglionic fibers travel on the auriculotemporal nerve to the parotid. Sympathetic innervation arises from the carotid plexus in a poorly defined manner. The sympathetic nerves have no control over secretion and act only as vascular secretion. Saliva is crucial for normal hygiene and serves an important digestive, immunologic and protective function. Any method of controlling sialorrhea should be based on maintaining a moist oral environment.

Although most cases result from neurologic cause, hypersecretion and indirect causes can rarely produce sialorrhea. True hypersecretion is seen in pregnancy, in response to local

irritation, and in side effects to tranquilizers and anticonvulsants. Indirect causes, such as nasal obstruction, malocclusion, microglossia or poor positioning lead to sialorrhea because of chronic mouth breathing or open mouth posture.

Causes of drooling in patients with cerebral palsy include: poor head control, constant open mouth, poor lip control, disorganized tongue mobility and decreased tactile sensation. Patient management is often performed by a multidisciplinary team, consisting of an otolaryngologist, a speech pathologist, and a dentist. The speech pathologist evaluates the probability of improvement of oromotor skills with time, therapy or both. The dentist assesses structural abnormalities and the health of the dentition and gingivae. The otolaryngologist examines for head and neck pathology and determines the extent of the drooling problem. The evaluation process considers age, degree of neurologic disability, expectations of the caregiver, patient's medical history and physical examination. Normal children drool until up to four years of age. Maturation of oral function continues in cerebral palsy children until six years of age. It is important to delay surgery in patients with acquired neurological disorders until the clinical state has plateaued for six months.

Assessment of the physical and social impact that drooling has on the patient's life and the lives of those caring for him is critical. The goal of therapy is to reduce drooling while maintaining a moist physiologic oral environment. A medical history may reveal a drug causing hypersecretion. Physical examination may identify structural factors contributing to drooling. Speech and behavioral modification, pharmacologic modalities, radiation or surgery. All may be a part of eventual therapy.

Nasal obstruction such as rhinitis or adenoid hypertrophy should be corrected. Procedures to correct malocclusion or dental disease may be required. Speech therapy has been disappointing overall but is intended to improve jaw stability, tongue mobility and strength, decrease nasal regurgitation and facilitate sensory awareness of mouth closure and swallowing. Behavior modification has been successful in a small group of patients with good insight and motivation. Therapy is labor intensive and regression is common. Anticholinergic drugs can be given orally to decrease salivary production. A Scopolamine patch will decrease saliva production for three days, but tolerance does develop, and side effects are common.

Radiation has been shown to produce glandular atrophy and decreases secretions; however, the dose required for atrophy may produce xerostomia. The potential risk of secondary - malignancy exists. Surgery is the most effective means for long term control of sialorrhea. Effective operations address the submandibular glands.

In 1964 Wilke first proposed a surgical approach for drooling. He transposed the parotid ducts to the tonsillar fossae and later added submandibular gland excision. This procedure does have post operative complications. Eighty-five percent of patients benefit from the procedure. Thirty-five percent of patients were reported to have complications. Salivary gland excision/ligation is advocated by a few authors. It is 90% effective; however, marginal mandibular nerve damage may occur.

Bilateral submandibular duct relocation has become a popular method for redirecting salivary output while maintaining function. The duct and a mucosal cuff is dissected free of the lingual nerve and then passed posterior to the anterior tonsillar pillar. A tonsillectomy is occasionally required if chronic tonsillitis or hypertrophy exists. Duct relocation has an 80% success rate. Ranulas form in 8% of cases and therefore sublingual gland excision is advocated.

Transtympanic neurectomy has a reported 80% effective rate treatment for sialorrhea. In this procedure both the chorda tympani and tympanic nerves are sectioned via an endural approach but all branches including the hypotympanic one must be addressed. In 50% of cases loss oftaste to the anterior two-thirds of the tongue occurs.

In summary, sialorrhea has both medical and social implications. Successful management relies on a team approach. No one therapy is the answer. Both medical and surgical therapy can be helpful in controlling this problem.

Case Presentation

An 8-year-old Latin American child with cerebral palsy presented to the Texas Children's Junior League Clinic for evaluation and treatment of drooling. Her drooling interfered with her schoolwork and interaction with other children and required frequent bib changes. She is of normal intelligence and her condition had not improved after eight months of speech therapy. Physical exam revealed adequate head control and a constant open mouth posture. No intraoral lesions or nasopharyngeal obstruction was identified. Modified barium swallow revealed a markedly abnormal oral phase of deglutition. She subsequently underwent bilateral submandibular gland resection and satisfactory postoperative results were obtained.

Bibliography

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